Brazilian nursing specific situation, middle and micro-range theories: a bibliometric study

ABSTRACT Objectives: to map the nursing theories developed in stricto sensu graduate programs in nursing in Brazil. Methods: a bibliometric study, carried out on the Coordination for the Improvement of Higher Education Personnel Theses and Dissertations Portal in October 2023. The controlled descriptors “Nursing Theory” and “Nursing Models” and the uncontrolled descriptors “Theories” and “Middle-Range Theory” were used. Selected studies were cataloged for analysis, which was conducted by the study authors, who have a doctoral degree and expertise in research on nursing theories. Results: thirty-nine nursing theories were mapped, with a predominance of middle-range theories (79.5%), focusing on nursing diagnostic concepts and use of the theoretical-methodology strategy of theoretical-causal validity. Conclusions: the study identified nursing theories developed in Brazil, recognizing trends, development strategies, theorized objects of disciplinary interest and investments necessary for practical application in Brazilian contexts.


INTRODUCTION
For decades, theorists and metatheorists have argued that nursing theories are relevant to knowledge and practice, producing something that could be recognized as a Nursing Theory Guide Practice (NTGP) paradigm.The theories have contributed to a unique knowledge base necessary for better understanding human phenomena and responses (1)(2) .
In 2020, Ahtisham Younas questioned the preponderance of NTGP by applying Imre Lakatos' philosophical criteria.It was pointed out a probable NTGP degeneration as a scientific research program, when compared to evidence-based practice and knowledge translation (3) .The argument for NTGP degeneration was supported by findings from an integrative literature review in English to examine the use of theories to guide experimental research and compare their usefulness with traditional nursing practice (3) , and from a review of 61 doctoral theses in nursing science produced in English between 1994-2015 at the University of Edinburgh, in the United Kingdom (4) .
On the other hand, there are studies that still indicate the current use of theories as a reference framework for research and practices and nursing theory development in English, particularly (5)(6) which would weaken the degeneration argument.
Brazil accounts for the majority of nursing production in Portuguese, and has worldwide relevance in training master's and doctoral professionals in the area as well as a tradition in the academic defense of NTGP.Studies covering the period from 1998 to 2019 demonstrate that, in Brazil, studies that used nursing theories are based mainly on North American theorists; however, they do not indicate the advancement or degeneration of the theorizing movement in Brazilian nursing (7)(8)(9) .
Brazilian authors published a literature review (10) based on articles to describe how middle-range theories (MRTs) for nursing were developed until 2016.Of the 25 studies found, none were published in Portuguese, and only one had Brazilian authors in its list (10) .However, there were already MRTs for nursing produced in the country and deposited in university repositories and in the Coordination for the Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) Journal Portal in the form of theses, which were not identified in the article.
Evidence indicates a gap in current knowledge about nursing theory development in Brazil.There is a growing interest in nursing theory development, especially middle-range ones (11) .Thus, our research question is: what is the overview of nursing theory production in Brazil according to dissertation and theses reports from graduate programs in nursing?
Graduate programs at universities are the main environments for nursing theory production in Brazil.Therefore, it is essential to look for dissertation and theses reports to understand the real state of knowledge about theories developed in Brazil.

OBJECTIVES
To map nursing theories developed in stricto sensu graduate programs in nursing in Brazil.

Ethical aspects
The research was not submitted for consideration by the Research Ethics Committee, since it was carried out with secondary data in the public domain.However, study copyright was preserved.

Study design, period and place
This is a bibliometric study carried out based on the analysis of dissertations and theses from Brazilian graduate programs in nursing deposited in the CAPES Theses and Dissertations Catalog.This type of work was chosen because it represents the high level of scientific production in the country, presenting methodological rigor in studies, validated by qualification boards.
The studies were located using the CAPES Theses and Dissertations Catalog search tool, using the Health Sciences Descriptors (DeCS): "Nursing Theory" and "Nursing Models".The terms "Theory" and "Middle-Range Theory" were also applied, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIS-MA) was implemented.There was no time frame delimitation.Data collection took place in October 2023.

Inclusion and exclusion criteria
Dissertations and theses that developed nursing theories without time span were included.Research that was not available online was excluded.

Study protocol
Data search and extraction were carried out by two researchers who were authors of the study.Any disagreements were discussed among all authors.
The following strategies were applied in the search field of the CAPES Theses and Dissertations Catalog: "Nursing Theory" (descriptor) OR "Nursing Theories" (keyword), with 260 studies found; "Nursing Models" (descriptor) OR "Nursing Model" (keyword), with 31 studies found; "Mid-Range Theory" (keyword), with 49 studies found; and "Theory" OR "Theories" (keywords), with 1,793 studies found.The filters "health sciences" from the "major area of knowledge" and "nursing"/"public health nursing"/"obstetric nursing"/"pediatric nursing" from the "area of knowledge" were used.After reading the titles and abstracts, 1,904 studies were excluded because they did not address theory development.The final sample consisted of 39 studies (Figure 1).

Analysis of results, and statistics
The data were recorded in an electronic spreadsheet that included information on the year of completion, study title, keywords, study objective, university, author, advisor, program, name of theory/model developed, study design, theoretical/ methodological framework and area of knowledge established by the authors (women's health, adult/elderly health, child/ adolescent health and mental health).The cataloged data were analyzed by the study authors, who have doctoral degrees and expertise in research on nursing theories, in addition to academic studies in this area.
Descriptive statistics with absolute and relative frequency were used to analyze the data, and the findings were presented in charts/tables.

RESULTS
Thirty-nine nursing theories were found, produced and disseminated in 26 (66.7%) theses and 13 (33.3%)dissertations, from 2012 to 2023, in 13 graduate programs in three geographic regions of Brazil.Chart 1 presents a summary of the profile of theories (T), organized in ascending order of year, informing the title of thesis or dissertation, institution, authors, advisors and main objectives.
Table 1 shows the region of Brazil where the graduate program of the authors of the theory is located and details the higher education institutions.
The predominant objectives of research were to create/develop nursing theories for ND validity, followed by clinical theorizations of conditions of interest to nursing, including for the proposition of prescriptive actions or connections with other elements of practice, such as nursing outcomes and interventions.Figure 2 establishes the temporal evolution between the generated/ created theories of NDs and others.
Most theories focus on diagnostic concepts, mainly from the NANDA International (NANDA-I) classification, which is a growing trend over the years from 2020 onwards.
The authors classified their theories into the typologies of middle and micro, and SST, employing nine theorizing methods/ strategies, as detailed in Chart 2.
thor: Jaqueline Santos de Andrade Martins Advisor: Marcos Antônio Gomes Brandão Propose a nursing theory for the process of interaction in virtual environments based on the theory-building strategies proposed by Walker and Avant.

Number year university
Thesis/dissertation Title Author Advisor Main objectives (T5) 2018 UECE Dissertation: Reabilitação cardiovascular: proposta de uma teoria de enfermagem de médio alcance (16) Author: Maria Sinara Farias Advisor: Lucia de Fatima da Silva Develop an MRT for nursing based on theorybuilding strategies proposed by Walker and Avant for the process of cardiovascular rehabilitation.
(T6) 2018 UECE Thesis: Teoria de enfermagem de médio alcance para adesão de pessoas ao tratamento de hipertensão arterial e diabetes mellitus (17) Author: Kalidia Felipe de Lima Costa Advisor: Maria Vilani Cavalcante Guedes Develop and validate a nursing MRT for adherence of individuals to treatment for high blood pressure and diabetes mellitus.
(T7) 2018 UFRN Thesis: Construção e validação do diagnóstico de enfermagem risco de volume de líquidos excessivo a partir de uma Teoria de Médio Alcance (18) Author  (22) Author: Larissa de Araújo Lemos Advisor: Marcos Venício de Oliveira Lopes Establish the validity of the ND Dysfunctional Ventilatory Weaning Response from NANDA-I and develop an MRT on dysfunctional ventilatory weaning.
(T12) 2019 UFPE Dissertation: Validação do conteúdo do diagnóstico de enfermagem "conhecimento deficiente em indivíduos com insuficiência cardíaca" (23) Author: Claudia Gabrielle da Silva Advisor: Cecília Maria Farias de Queiroz Frazão Validate the content of the ND Deficient Knowledge in individuals with heart failure and build an MRT with the identification of attributes, antecedents and consequences.
(T13) 2020 UFRJ Thesis: Teoria do risco de padrão glicêmico desequilibrado em adultos e idosos com diabetes mellitus em tratamento (24) Author: Rafael Oliveira Pitta Lopes Advisor: Marcos Antônio Gomes Brandão Develop a theory on glycemic variations in adults and older adults with diabetes mellitus undergoing treatment, based on Roy's Conceptual Adaptation Model.
(T14) 2020 UFC Thesis: Teoria de situação específica e análise de conteúdo do diagnóstico de enfermagem nutrição desequilibrada: menor do que as necessidades corporais em crianças com câncer (25) Author: Iane Ximenes Teixeira Advisor: Marcos Venício de Oliveira Lopes Develop two stages of the ND validity process in order to obtain evidence of theoretical and content validity of the ND Imbalanced Nutrition: Less than Body Requirements in the context of children with cancer.

Thesis:
Validação do diagnóstico de enfermagem rede social de apoio ineficaz (27) Author: Michelline Santos De Franca Advisor: Cleide Maria Pontes Validate the ND Inadequate Social Support Network and develop the MRT Inadequate Social Support Network.
(T17) 2020 UFC Thesis: Validação do diagnóstico de enfermagem proteção ineficaz em adolescentes com câncer (28) Author: Marilia Mendes Nunes Advisor: Marcos Venício de Oliveira Lopes Establish a diagnostic structure that represents evidence of validity for inference of the ND Ineffective Protection in adolescents with cancer and construct an MRT.

Number year university
Thesis/dissertation Title Author Advisor Main objectives (T20) 2021 UFRN Dissertation: Sobrepeso em adolescentes e adultos jovens: uma teoria de médio alcance (31) Author: Ana Carolina Costa Carino Advisor: Ana Luísa Brandão de Carvalho Lira Construct an MRT for the ND Overweight in adolescents and young adults.
(T25) 2022 UFSM Thesis: Microteoria para cuidados de enfermagem na prevenção do delirium em pessoas idosas na unidade de terapia intensiva (36) Author: Sandra da Silva Kinalsk Advisor Margrid Beuter Develop a prescriptive microtheory for nursing care in delirium prevention in older adults in the Intensive Care Unit based on constructs from Callista Roy's Adaptation Model.
(T28) 2022 UFRJ Thesis: Teoria de médio alcance do processo adaptativo da pessoa com lesão na medula espinhal baseado no modelo de adaptação de Roy (39) Author: Kenia Rocha Leite Zaccaro Advisor: Marcos Antônio Gomes Brandão Construct an MRT of the adaptive process of a person with traumatic spinal cord injury based on Callista Roy's Adaptation Model.

Number year university
Thesis/dissertation Title Author Advisor Main objectives (T34) 2022 UFC Dissertation: Validação de conteúdo do diagnóstico de enfermagem "síndrome pós-trauma" no contexto da violência contra a mulher (45) Author: Yanka Alcantara Cavalcante Advisor: Marcos Venício de Oliveira Lopes Verify the structural validity of the ND Post-Trauma Syndrome (PTS), through the production of two stages, such as construction of a situationspecific theory (SST), through the phases of an MRT, and content validity by judges.
(T35) 2023 UFRJ Thesis: Teoria do risco de quedas em pessoas idosas na comunidade (46) Author: Jéssica de Castro Santos Advisor: Marcos Antônio Gomes Brandão Construct a nursing theory on the risk of falls in older adults in the community.

DISCUSSION
The mapping carried out provides evidence of a growing movement of development of nursing theories by master's and doctoral students in Brazil, mainly from 2018 onwards, after the four (12)(13)(14)(15) pioneering studies verified from 2012 to 2017.This finding contradicts the idea of a degeneration in the nursing theory research program in the country, particularly for MRT for nursing.
It is difficult to assess the scope of the use of nursing theories as a framework for professional practice or in clinical nursing research, since it always requires the analysis of hundreds of studies that do not always clearly explain the theoretical frameworks.On the other hand, it is easier to map theoretical construction as a research enterprise.Such theories are basically created to constitute a basis for ND validity for the description, explanation or prediction of phenomena and conditions of interest for clinical practice or to prescriptively guide professional practice.
We also found that the movement that began in southeastern Brazil gradually spread to the northeast and then to the south.This spread is relevant for the expansion of theorizing, with the possibility of expanding capillarization and incorporating cultural and regional traits of a country of continental dimensions.
The predominance of theories developed in northeastern Brazil, accelerated from 2020 onwards, is associated with the relevant contribution of this region of the country in the development of research in ND theoretical-causal validity.The current criteria for the levels of evidence of NANDA-I NDs foresee the development of a theoretical foundation at the level of theoretical-causal validity (52,61) .The growth of graduate programs in Brazil, encouraged by the CAPES National Graduate Plan (PNPG 2011-2020), may also be related to this movement (62) .
We can interpret as an effort to theorize for clinical nursing practice the fact that 38 nursing theories address diagnoses or conditions of human groups or populations.Whether for groups of adults, older adults, children, women or groups with specific health problems, the theories communicate a direction for instrumentation of particular conditions of nursing care, moving away from more general themes or constructs, such as grand nursing theories.It also indicates less interest in theorizing the dimensions of teaching or management of professional practice (9) .
The limited focus also appears to be related to the predominant typologies of MRT, McT and SST.Such findings reinforce the perspective of levels of theoretical thinking, in which middle-range ones would have scope and abstraction between the specific to guide practice and research, however without losing the ability to assist different populations with the same phenomenon.
The predominance of MRTs, verified in mapping, converges with the trend of global theorization in nursing, which was observed from philosopher Frederick Suppe's considerations on the structure of scientific theories and possibly from his presentation "Middle range theories: what they are and why nursing science needs them", held in 1993, at the Council of Nurse Researchers Symposium of the American Nurses Association (ANA) (63) .Since then, there has been a continued interest in MRT construction to clarify, describe, prescribe and predict the phenomena, scenarios, facts, situations and interventions that are part of everyday nursing practice, contributing to the advancement of research and science in nursing (64) .
SSTs were the second most frequently verified typology in mapping, and they are also of low level of abstraction.In their original format, they followed more practical, contextualized and cultural traits compatible with the vocation of the University of California at San Francisco School of Nursing (6) .Among the philosophical roots that drive SSTs is post-empiricism, which aims to predict the experiences and responses of a given group of human beings under certain health and disease conditions (65) .However, currently, both the strategies for creating SSTs and the philosophical foundations are several (65) .
At the lowest levels of theoretical thinking, McTs are the least formal, restricted in time, scope and application, comprising groups of hypotheses of works or propositions (63) .This research identified the use of theoretical substructure as a strategy for creating the only microtheory (36) identified.
Finally, the third type of theory at the lowest level of abstraction, which are practical theories, were not found in this review.Practical theories emerged in the 1960s based on the considerations of Dickoff et al. (66) with a practice-oriented theorizing approach, with levels of factor isolation, factor relationship, situation relationship and situation production.Such theories would have the ultimate goal of modifying reality by prescribing situations, which depended on the preliminary stages of concept isolation with description, concept relationship and predictive statements (6) .
However, only recently, with the development of taxonomies and other types of theories, have theories of practice been able to advance to contemporary challenges, through the use of methods such as integrated classification-theory strategy (2) .
The predominance of strategies of synthesis, derivation and analysis of concepts, statements and theories was verified in non-diagnostic nursing theory elaboration.For Des' theories, theoretical-causal validity strategy predominated.
In synthesis strategy, information based on observation is used to construct a new concept, a new statement, and a new theory.Derivation consists of transposing or redefining a concept, statement, and theory from one context or field to another.Meanwhile, in analysis, the theorist must dissect the whole into parts so that it can be better understood.Each of these strategies can be used to develop concepts, statements, and/or theories (51) .
The theoretical-causal validity strategy (52) has driven the theoretical foundation for ND validity since 2017.This strategy, which is based on Roy's model (6) , proposes theoretical development based on the following steps: definition of MRT construction approach; definition of theoretical-conceptual models to be analyzed; definition of MRT's main concepts; development of a pictorial scheme; construction of MRT propositions; establishment of causality and evidence relationships for practice (52) .Theorizing strategies that are not widely recognized in nursing were used more by theorists from southeastern and southern Brazil (T3, T8, T13, T25, T28, T29 and T35), indicating a tendency towards the use of new methods.
We can state, based on the research objectives and the elements produced in theorizing, that theorists were concerned with translation of knowledge, since, for the most part, they proposed some element of a more operational nature, such as diagrams, terminological subsets, action/intervention guides, links between diagnoses, ouctomes and interventions, among others.Although the classic elements of theoretical construction were present, such as concepts, premises, statements, propositions and iconic models, the authors predominantly produced explanatory, predictive or prescriptive elements in their theories, which brings an interesting approach to how much these theories could contribute to the purposes of practical theories and NTGP.
This aspect of theories approximated to practice conditions produces a counterpoint to the criticism of the relevance of nursing theories to the nursing profession.Perhaps the essence of this criticism is based on some clinicians' perception about some of the grand North American nursing theories.The theory-practice gap has been described in the United States of America between 1980 and 1990, encompassing differences between the theories taught in the classroom and the practice found in the areas of clinical practice or even the existence of a disconnect between theoretical and practical realities (67) .
Thus, the progression of theoretical research verified in Brazil may be a factor that prevents or minimizes the NTGP program degeneration in Brazil, by offering new references that guide research and clinical practice.The mapped theories have a scope for clinical practice conditions or preparation for its exercise in challenging scenarios (virtual environments -T1).
Furthermore, the content of these theories may include regional aspects and the characteristics of the country's health system.In fact, there must be an alignment between nursing theories and professional practice in order to achieve good and best practices, especially to collaborate in solving the challenges of the Brazilian Health System (68) .

Study limitations
The study has some limitations.Full access to theses and dissertations depended on their location on the CAPES portal or in institutional repositories.Thus, theories that had not yet been deposited or were not in digital format may not have been included in mapping.To mitigate these limitations, a free search was conducted on the internet for the titles of selected dissertations and theses.
Another limitation was the use of a limited set of descriptors in the portal.Although we applied controlled descriptors and relevant uncontrolled terms, this restricted selection may result in loss of relevant studies, such as those related to theories produced by the GT method.It is worth noting that, although GT produces theories, its meaning of substantive and formal theories is usually not considered by researchers in this field as aligned with the most widespread idea of nursing theories.Given this little advanced debate, we chose to consider only theories in which the authors clearly announced a perspective convergent with the vision of nursing theories adopted in this study.

Contributions to health and nursing
The research presented perspectives on scientific production of Brazilian nursing theories, highlighting the need to value and develop other studies, such as those validating and applying these theories.
Mapping enabled an understanding of the diversity and breadth of nursing theories developed in Brazilian academic contexts, offering insight into the current knowledge landscape in the field.Moreover, it provided valuable insights for improving graduate programs in nursing, allowing academic institutions to adjust their curricula and research approaches according to identified needs and trends.The study also helped identify areas in which nursing theories have not yet been widely explored or developed, highlighting potential gaps in knowledge that could be targets for future research.

CONCLUSIONS
The bibliometric study made it possible to understand the nursing theories developed in graduate programs in Brazil, which represents an advance in the production of this knowledge in professional development and in the adoption of a practice program based on theories.
The advancement of nursing over the years is notable, with an increase in the production of theses and dissertations with research into nursing theory development.MRTs were the most prevalent in this bibliometrics and are continually growing, however, with studies still limited in the theoretical-methodological detail of its construction, which makes it difficult to consult theses and dissertations as educational material for developing theories.However, the use of these scientific studies in the country is still incipient, considering that theories support nursing science.Therefore, it is necessary to disseminate Brazilian nursing theories so that they can be incorporated into care practice (as support in nursing process implementation), teaching and research.

CONTRIBUTIONS
Cardoso RB, Brandão MAG and Primo CC contributed to the conception or design of the study/research.Cardoso RB, Brandão MAG, Cavalcante JCS, Lopes ROP and Primo CC contributed to the analysis and/or interpretation of data.Cardoso RB, Brandão MAG, Lopes ROP, Zaccaro KRL and Primo CC contributed to the final review with critical and intellectual participation in the manuscript.

Figure 2 -
Figure 2 -Evolutionary distribution of theories focusing on nursing diagnoses and other central conditions or concepts (n=39), Rio de Janeiro, Rio de Janeiro, Brazil, 2023

Table 1 -
Characterization of dissertations and theses according to the regions of Brazil and higher education institution (n=39), Rio de Janeiro, Rio de Janeiro, Brazil, 2023 Description of theorizing methods/strategies related to the type of theory developed (n=39), Rio de Janeiro, Rio de Janeiro, Brazil, 2023